Form DOE F 206.5 DOE F 206.5 Privacy Act Information Request

CUI//PRVCY
when filled in

DOE F 206.5 (09/2024)
PREVIOUS EDITIONS ARE OBSOLETE

U.S. DEPARTMENT OF ENERGY
PRIVACY ACT INFORMATION REQUEST

OMB Control No. XXXX-XXXX
Expires: MM/DD/YYYY

Consent For Disclosure of Records Under the Privacy Act
To provide consent and authorize the agency to disclose your records to another person or entity, please provide the information below.
This form may also be used if you are the parent consenting to and authorizing disclosure of the records of a minor or the legal guardian
consenting to and authorizing disclosure of the records of an incompetent. Please complete the appropriate Items in Part I, II, III and
establish identity in accordance with instructions on page 3 of this form. Retain a copy for your records. Submit signed and completed
Privacy Act Request Information form and a copy of identifications to the U.S. Department of Energy Privacy Act Office in accordance
with instructions on page 3 this form. Requests may also be submitted to a Privacy Act Officer at a Field Location or National Lab.
NOTE: Records will be provided in Adobe PDF format and copied to a CD-ROM, thumb drive, or emailed password protected unless the
requester states a preference for paper copies. Part IV is For Agency Use Only.
FALSE STATEMENTS SUBJECT TO CRIMINAL PENALTIES. SEE PAGE 3.
Privacy Act Statement
Authority: The Privacy Act of 1974 (5 U.S.C. § 552a) and 10 CFR § 1008.7 authorizes the collection of this information. The information
provided through this form is covered by a DOE Privacy Act system of record, DOE-55, Freedom of Information and Privacy Act
(FOIA/PA) Request for Records, which is located in volume 74 of the Federal Register, pages 1059-1061, published on January 9, 2009.
Purpose: DOE will use this information to search for records pertaining to a specific individual when a Privacy Act information request is
submitted by that individual or by an authorized representative on behalf of that individual.
Routine Uses: This information will be used by and disclosed to DOE personnel, contractors, or another federal agency who will need the
information to locate records responsive to your request. DOE may disclose this information in courts or in administrative proceedings, to
the tribunals, counsel, other parties, witnesses, and the public (in publicly available pleadings, filings, or discussion in open court) if the
disclosure is relevant and necessary for the proceeding and compatible with the purpose for which the Department originally collected this
information. Additionally, this information may also be disclosed to members of Congress making requests on behalf of a constituent. This
information may be provided to DOE employees or contracts who have a need for the information in the performance of their duties or to
fulfill contact requirements, pursuant to the purpose established in DOE-55.
Disclosure: Furnishing this information (including additional identifying data) is voluntary; however, failure to furnish the requested
information may delay or increase of difficulty of locating records responsive to your request.

Part I – Information Used for Identity-Proofing and Authentication
(This information is required for the agency to verify your identity)

1. Full Name (First, Middle, Last)

2. Date of Request

If applicable: Information for Request by Parent or Legal Guardian
3. Full Name of Individual whose Record(s) are Requested (First, Middle, Last)

4. Documents Required to Establish Relationship/Guardianship
(Check all that apply)

Court Order establishing guardianship
5. To Verify My Identity:

Birth Certification

I have completed and signed this form with a physical or digital signature.
I have enclosed a copy of two identifying documents bearing name and signature, one of which bears current home or business
address and date of birth, such as a driver’s license, passport, voter’s registration, insurance card, etc., or
I have provided in person, a copy of a document containing my photograph and signature; or two documents containing my name
and signature, one of which contains my current address and date of birth, such as a driver’s license, passport, voter registration
card, etc., or
I have a representative authorized by the individual whose records are being requested. I have submitted a notarized General
Release form/letter indicating the individual has given permission to release the records to the Authorized Representative, an
Authorization for Representative form/letter giving them permission to act on their behalf, copies of two (2) forms of ID from the
individual whose record(s) are requested, and two (2) forms of ID from the authorized representative.

DOE F 206.5 (09/2024)

Controlled by: U.S. Department of Energy, Privacy Program, [email protected]

Section 508 Compliant

CUI//PRVCY
when filled in

DOE F 206.5 (09/2024)
PREVIOUS EDITIONS ARE OBSOLETE

OMB Control No. XXXX-XXXX

U.S. DEPARTMENT OF ENERGY
PRIVACY ACT INFORMATION REQUEST

Expires: MM/DD/YYYY

Part II – Additional Information Required to Locate the Record(s)

(This information is required for the agency to be able to match the individual’s information provided in this request with the records that pertain to that individual)
6. Social Security Number

7. Date of Birth (MM/DD/YYYY)

8. Program Office, Staff Office, Field Office, or Lab that you are Requesting Records From

9. Date Range of Records Requested

10. Give any identifying data that would help locate the record (e.g., maiden name, badge number, occupational license number, time and place of employment, etc.)

11. Description of Requested Records

Administrative Review Files
Grievance Files
Medical
Occupation and Industrial Records
Payroll/Leave Records

Other (Type of Records Requested)

Personnel Records
Personnel Security Clearance Files
Radiation Exposure Report
Training Records
X-Ray Reports

Part III – Recipient Information
12. Name of Recipient (Person or Entity) to Whom Disclosure is Authorized
(First, Middle, Last)

13. Recipient’s Relationship to the individual who is the subject of the records

Parent or a Minor
Legal Guardian
Third-party representative authorized by the individual
Member of Congress:

14. Recipient’s Mailing Address

(Name and State)

15. Requester’s Contact Information

Telephone Number (Include Area Code):

Email Address:

16. Declaration

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that I am the
person named above and requesting access to my records [, or records that I am entitled to request as the parent of a minor or the legal
guardian of an incompetent], and I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. §
1001 by a fine, imprisonment of not more than five years, or both, and that requesting or obtaining any record(s) under false pretenses is
punishable under the provisions of 5 U.S.C. § 552a(i)(3) by a fine of not more than $5,000.
17. Requester’s Digital Signature

18. Date

Part IV – For Agency Use Only
19. Proof of Identity Witnessed in Person (Name, Title, Location)

20. Case Number

21. Form of Identity

22. Action Assigned To/Date

Driver’s License (Date Received)
Passport
(Date Received)
Other

DOE F 206.5 (09/2024)

23. Additional Identifying Information

Page 2 of 3

Controlled by: U.S. Department of Energy, Privacy Program, [email protected]

Section 508 Compliant

DOE F 206.5 (09/2024)
PREVIOUS EDITIONS ARE OBSOLETE

CUI//PRVCY
when filled in

U.S. DEPARTMENT OF ENERGY
PRIVACY ACT INFORMATION REQUEST

OMB Control No. XXXX-XXXX
Expires: MM/DD/YYYY

Ways to Submit a Privacy Act Request:
1) By Mail: The Privacy Act Office, United States Department of Energy, 19901 Germantown Road, Room G-302, Germantown,
Maryland 20874; or
2) By Fax: 301-903-7738 Attn: Privacy Act Request.
3) By email as a password protected document: [email protected]
4) At a DOE Field Location: Individuals may make arrangements with the appropriate Privacy Act Officer to submit a Privacy Act
request at a Field Office or National Lab location. Contact information for local Privacy Act Officers may be accessed here:
https://www.energy.gov/cio/privacy-program.
Establishing Valid Identification of Individual Making Request Under the Privacy Act:
Pursuant to 10 CFR, § 1008.4 (b) (1) and (b) (2), an individual making a request may establish identity by:
1) Including with the request, if submitted by mail or email, a photocopy of two identifying documents bearing name and signature,
one of which shall bear current home or business address and date of birth; or
2) Appearing at the appropriate DOE Headquarters of Field location during business hours and presenting either of the following:
i.
One identifying document bearing the individual’s full name, photograph, and signature; or
ii.
Two identifying documents bearing the individual’s full name and signature, one of which shall bear their current home or
business address and date of birth.
If the individual making the request is unable to produce satisfactory evidence of identity, the individual making the request may be
required by the Privacy Act Officer to submit a notarized statement attesting to his identity and his understanding of the criminal penalties
provided under Section 1001 of Title 18 of the United States Code for making false statement to a Government agency and under
subsection (i)(3) of the Act for obtaining records under false pretenses.
Section 5 USC 55a (i) – Criminal Penalties:
1) Any officer of employee of an agency, who by virtue of his employment or official position, has possession of, or access to ,
agency records which contain individually identifiable information the disclosure of which is prohibited by this section or by
rules or regulations established there under, and who knowing that disclosure of this specific materials is so prohibited, willfully
disclosures the material in any manner to any person or agency not entitled to receive it, shall be guilty of a misdemeanor and
fined not more than $5,000.
2) Any officer of employee of any agency who willfully maintains a System of Records without meeting the notice requirements of
subsection (e) (4) of this section shall be guilty of a misdemeanor and fined not more than $5,000.
3) Any person who knowingly and willfully requests or obtains any record concerning an individual form an agency under false
pretenses shall be guilty of a misdemeanor and fined not more than $5,000.
Other Penalties:
A person who falsely or fraudulently attempts to obtain records under the Privacy Act, Title 5 U.S.C. Section 55a, may also be subject to
prosecution under other criminal statues such as 18 U.S.C. 494, 495, and 1001.
OMB Disclosure Statement
This data is being collected to comply with the mandatory OMB M-21-04 templates for individuals to submit requests for accessing and
consenting to the disclosure of records protected under the Privacy Act of 1974, as amended, 5 U.S.C. 552a. The data you supply will be
used for the search of records pertaining to a specific individual when a Privacy Act information request is submitted by that individual or
by an authorized representative on behalf of that individual.
Public reporting burden for this collection of information is estimated to average .33 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to Office of the Chief Information Officer, Enterprise Policy Development & Implementation Office, IM-22,
Information Collection Management Program (1910-1700), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC
20585; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Program (1910-1700), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for
failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of
information displays a currently valid OMB control number. Submission of this data is voluntary.
DOE F 206.5 (09/2024)

Page 3 of 3

Controlled by: U.S. Department of Energy, Privacy Program, [email protected]

Section 508 Compliant